• Resuscitation of the critically ill septic patient should

occur concu rrent or before diagnostic evaluation.

CLINICAL PRESENTATION

..... History

Any patient presenting with an infectious syndrome should

be considered for potential sepsis. Those at the extremes of

age or the immunosuppressed may not mount a fever. Other

patients may have defervescenced before triage vital signs.

High clinical suspicion will be required in properly identifying these patients. Furthermore, patients with reduced

physiologic reserve are at risk for rapid clinical deterioration.

History should elicit the source of infection. Straightforward complaints include cough, purulent phlegm,

headache with stiff neck, dysuria, or rashes. More subtle

cues include fluctuating mentation suggesting delirium;

rigors suggest influenza, pneumonia, and biliary sepsis;

and fevers shortly after administration of total parenteral

nutrition (TPN) suggest central line infection.

..... Physical Examination

As with all potentially unstable patients, airway, breathing,

and circulation (ABCs) should be assessed on arrival. Vital

signs should be assessed next, remembering that lack of

fever does not exclude infectious etiology. Tachycardia may

be a response to fever, or it may represent a physiologic

1 42

Table 34-1. Diagnostic criteria for sepsis.

Infection, documented or suspected, and some of the following:

General variables

Fever (>38.3°C)

Hypothermia (<36°()

Heart rate >90 beats/min

Tachypnea

Altered mental status (delirium)

Significant edema or positive fluid balance

(>20 mL/kg over 24 hrs)

Hyperglycemia (>140 mg/dL) in the absence of diabetes

Inflammatory variables

Leukocytosis (WBC count >12,000/�L)

Leukopenia (WBC count <4000/�L)

Normal WBC count with >10% immature forms

Plasma (-reactive protein > 2 SD above the normal value

Plasma procalcitonin >2 SD above the normal value

Hemodynamic variables

Arterial hypotension (SBP <90 mmHg; MAP <70 mmHg; or an SBP

decrease >40 mmHg in adults or >2 SD below normal for age)